Few topics in child and adolescent mental health have generated as much controversy over the last decade as the debate about the safety of antidepressant medication given to kids. In 2004, the FDA issued a “black box” warning claiming that antidepressant use in children and teenagers is associated with increases in suicidal thinking and behavior, which was expanded in 2007 to include adults between the ages of 18 and 24. In my opinion, the larger controversy about antidepressant use in children and teens is not “are they safe?” but “do they work?” and if they work, what do they work for? Some of those questions were addressed here.

In an effort to help parents make sense of what they read and hear, we’ll examine the findings of two large studies.

The first study (funded by the National Institute of Mental Health) was conducted by Dr. Jeff Bridge and his team at the University of Pittsburgh, analyzing results of 27 clinical trials of antidepressants…fifteen studies involved kids with depression, six with Obsessive-Compulsive Disorder (OCD) and six with non-OCD anxiety…encompassing 5,310 patients under the age of 19.

Important take-home points…

No child or adolescent patient to date in any trial of antidepressant medication submitted to the FDA or included in Dr. Bridge’s analysis actually committed suicide.

The number of patients who must receive a specific treatment for one to benefit (Number Needed to Treat-NNT) or for one patient to be harmed (Number Needed to Harm-NNH) varied for antidepressants depending upon the condition the child or teen was receiving treatment for in the study.

Major Depression: Number Needed to Treat=10 Number Needed to Harm=112

OCD: Number Needed to Treat=6 Number Needed to Harm=200

Non-OCD Anxiety: Number Needed to Treat=4 Number Needed to Harm=143

To clarify, patients with depression were eleven times more likely to experience significant benefit from antidepressant medication than to experience medication-related suicidal thinking or behavior, patients with OCD were thirty-four times more likely to experience benefit and patients with non-OCD anxiety were thirty-six times more likely to experience benefit.

The second study (also funded by the National Institute of Mental Health) was conducted by researchers at the University of Chicago examined suicidal thoughts and behaviors in 9,165 patients (including 708 youth) treated with fluoxetine or venlafaxine for depression (all of the youth were treated with fluoxetine). In the four studies of youth on fluoxetine, the medication was effective in treating symptoms of depression, and no evidence of increased suicide risk was seen. At the same time, there was no evidence that a reduction in depressive symptoms produced a decrease in suicide risk in youth, as is the case with adults. The author of the study has speculated that other factors beyond depressed mood likely contribute to suicidal thinking and behavior in kids.

So…what advice do I give to parents around use of antidepressant medication when they ask “What would you do if this was your kid?”

First, I’d point out that the potential benefits of medication appear to outweigh the potential risks, especially for kids with anxiety, but in my experience the risk of an increase in suicidal thoughts/behavior associated with antidepressant medication appears to be greater than zero. I would be most concerned about an increased risk in kids with some other condition (in addition to depression or anxiety) that interferes with emotional self-regulation and/or impulse control (ADHD, trauma, kids with behaviors similar to those seen in Borderline Personality Disorder). One hypothesis put forth to explain a possible increase in risk involves the suggestion that antidepressants might cause disinhibition n a subset of patients…the pathways in the prefrontal cortex of the brain don’t fully mature for most people until their early to mid-20s, coinciding with the time after which antidepressants are no longer associated with increased suicidal risk.

Second, since cognitive-behavioral therapy (CBT) appears to be an effective alternative to medication for kids with anxiety and depression, kids with mild to moderate symptoms should probably receive a trial of CBT prior to a trial of medication.

Finally, I remind parents that antidepressants have been shown to be of significant benefit in kids with anxiety, moderately effective in kids with OCD and of modest benefit in kids with depression. It’s also important that parents understand the limitations of medication and the evidence suggesting medication use offers no guarantee that a child won’t make a serious suicide attempt.

Key Ministry has assembled resources to help churches more effectively minister to children and adults with ADHD, anxiety disorders, Asperger’s Disorder, Bipolar Disorder, depression and trauma. Please share our resources with any pastors, church staff, volunteers or families looking to learn more about the influence these conditions can exert upon spiritual development in kids, and what churches can do to help!

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About Dr. G

Dr. Stephen Grcevich serves as President and Founder of Key Ministry, a non-profit organization providing free training, consultation, resources and support to help churches serve families of children with disabilities. Dr. Grcevich is a graduate of Northeastern Ohio Medical University (NEOMED), trained in General Psychiatry at the Cleveland Clinic Foundation and in Child and Adolescent Psychiatry at University Hospitals of Cleveland/Case Western Reserve University. He is a faculty member in Child and Adolescent Psychiatry at two medical schools, leads a group practice in suburban Cleveland (Family Center by the Falls), and continues to be involved in research evaluating the safety and effectiveness of medications prescribed to children for ADHD, anxiety and depression. He is a past recipient of the Exemplary Psychiatrist Award from the National Alliance on Mental Illness (NAMI). Dr. Grcevich was recently recognized by Sharecare as one of the top ten online influencers in children’s mental health. His blog for Key Ministry, www.church4everychild.org was ranked fourth among the top 100 children's ministry blogs in 2015 by Ministry to Children.

Every child’s response to antidepressants — or any medication — are individual, and some reactions can go spectacularly wrong. In our case, our only child, at age 17 was given a tricyclic antidepressant called anafranil. After the first dose, four hours later she was having siezures, sensations of great cold, hypersensitivity to light and to normal sound levels. Even touching her was excruciating for her. Those siezures and other side effects lasted for years. She still suffers movement disorders and what seem to us to be partial siezures 17 years later. (Sudden unexplained changes in mood, “altered” states of mind or personality, odd smells and so forth often accompany partial siezures. Some of these “auras” also accompany her hemiplegic migraines, which resulted from other medical attempts to help her with depression.) She has been on full disability since 2001, unable to complete college or hold a job. She is on high levels of anti-stroke medication on account of her migraines and she is in bed on average 18 hrs a day. If the medical profession really wished to advance helpfully, it seems to me it would develop tests to screen patients accurately to see if this or that drug would help, harm, or do nothing for them. The “let’s try this and see what happens” routine is antique, outdated and irresponsible when reactions and side effects can be so devastating.

I’m so sorry to hear about your daughter’s experience with medication. I’ve prescribed Anafranil for some of our patients with obsessive-compulsive disorder for over 25 years and haven’t personally experienced a reaction as severe as you describe. It’s not typically the first medication we use because more side effect monitoring is required than with serotonin repute inhibitors, and side effects may be more of a concern with some drug combinations.

We’re beginning to see some commercially available tests in the last couple of years (because of the rapidly declining costs of genetic testing) that some psychiatrists are using to help anticipate risk for potential drug interactions. Most of this research is privately funded. The genetics determining medication response are far more complicated and to this point, and colleagues developing tests to predict treatment response have encountered far less success. The National Institute of Mental Health is focusing resources on understanding the underlying causes of traits associated with mental illness that occur across diagnostic categories with the hope of developing entirely new treatments based upon our understanding of causes at the genetic and cellular level. They’re no longer funding research based upon our current diagnostic system in mental health because the diagnostic categories and criteria are seen as arbitrary and aren’t necessarily grounded in an understanding of the underlying pathology.

I very much hope other families won’t experience problems similar to those your daughter has experienced in the not too distant future.

Dr Grcevich, thank you for your reply, and for your information re testing for reactions to meds. My daughter also had adverse reactions to Prozac. The psychiatrist working with her tried that several months after the anafranil reaction, and at first she seemed to do well on a low dose (10mg, I think once or twice a day), then she began to decline. I put in about 60 hrs online (late 1990s) looking for answers, and came across a “prozac survivors page” which listed about 40 adverse responses to Prozac, of which my daughter had 20. (I had been pretty suspicious of lawsuits over Prozac, figuring the plaintiffs’ problems might be due to other things. My mind got changed!) The next time we saw the psychiatrist to tell her my daughter’s symptoms, she said immediately “It’s serotonin syndrome, get her off the Prozac.” I had reached the same conclusion. Right now daughter takes Cymbalta, I think to help combat her “Pure-O OCD,” plus xanax for anxiety. The Medical University of Charleston follows her for neurological complications, primarily for her hemiplegic migraines, for which she takes very high doses of verapamil to ward off stroke. (Our ophthamologist passed away at age 50 about 15 months ago from a stroke due to this sort of migraine.) MUSC’s juvenile arthritis division determined she also suffers from fibromyalgia. She takes stomach acid inhibitors for GERD, and I have often wondered if that may be a result of adverse reaction to Prozac, since I read that most serotonin receptors are in the digestive tract. Yesterday my wife’s physician said my wife’s blood tests showed she suffers from extreme Vitamin D deficiency (hence exacerbations of her rheumatoid arthritis joint pain, excessive tiredness, etc.). We hope the MUSC physician will examine our daugher for the same deficiency, since she rarely goes outdoors. We read that Vitamin D deficiency can play heck with fibromyalgia and other issues she has. My daughter is generally very proactive about her health issues and reads voluminously, but the Vit D condition is one she missed!

I very much enjoy your newletter and agree wholeheartedly with the need to incorporate an informed ministry to the mentally ill into church ministries. So often, people simply do not know how to react, or as you have pointed out, blame poor self-discipline or sin for mental illness. While our church has no specific ministry to the mentally ill, there seems to be a general awareness that mental illness is a real phenomenon that is not always (or even primarily) due to a sinful failure of some kind. There is an unmarried gent who attends our church services and 6am men’s Bible study who has several difficult mental health conditions. He is on heavy medications, but is obviously intelligent. He is often very hard to understand when he speaks (med side effects), but we all seek to understand him clearly, and we clearly see he wants and needs the fellowship (he lives in a group home, doesn’t drive, etc.). He asks us often if we understand him, and if not to get him to repeat himself. He does have a sense of humor, and he welcomes our nudging him out of the “rabbit trails” his mind wanders into. Nobody has had the poor judgement to say his condition is due to his sins somehow. His own account is that his present problems followed two periods of serious illness in childhood, though he hasn’t detailed exactly what those illnesses were. Our daughter rarely attends services because she is back in bed after breakfast — her morning meds are rather soporific.